Positioning Incision and Exposure

The patient positioning, appropriate incision placement, and selection of the optimal approach for tumor exposure are the critical elements of successful meningioma surgery. The patient is positioned in such a way that the patient's safety is maximized. Moreover, the ideal position must allow for an approach that provides complete exposure of the tumor and the involved surrounding bone and dura. At the same time, maximal brain relaxation must be achieved by use of gravity and uncompromised venous drainage. The head should be no lower than the level of the heart, regardless of the position selected, and undue severe neck rotation or flexion must be avoided. In addition, surgeon's comfort for the duration of surgery must be maintained. The sitting position, preferred by some neurosurgeons for tumors of the pineal and select posterior fossa locations, places the patient at a higher risk of developing air embolism and the surgeon at an increased level of discomfort. When considering the sitting position for the aforementioned lesions, pre-operative sagittal MRI should be reviewed carefully to appreciate the relative size of the posterior fossa and the steepness of the tentor-ial angle. Patients with a small posterior fossa usually have a low-lying posterior tentorial attachment because of the inferior location of the torcular and inion. This anatomical variation leads to a very steep, nearly vertical tentorial angle, making the infratentorial/ supracerebellar approach with the patient seated extremely difficult. Other approaches to

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